Ivory Coast: the benefits of ART

From the Ivory Coast, a study found that giving antiretroviral treatment to
people early would reduce the likelihood that they would infect their
partners by 90%, without any increase in potentially risky sexual
behaviour.

The
Temprano study was run by the French AIDS research institute ANRS and
randomised 957 people with HIV in Abidjan, Ivory Coast, either to immediate treatment or to treatment when people's
CD4 count fell below what was then the World Health Organization's
threshold for treatment initiation of 200 cells/mm3. The trial took place between
January 2009 and September 2011 and halfway through, in early 2010,
the WHO revised its treatment threshold upward to 350 cells/ mm3. The study changed its threshold accordingly (at the IAS 2013 conference another
revision upward to 500 cells/ mm3
was announced).

The
trial had the unusual feature that its participants were largely
female: 80.5% were women. Twelve months after enrolment, participants
were asked to fill out a behavioural questionnaire and the researchers compared behavioural
characteristics and viral load in early versus guideline-treated
participants.

They found very little difference in sexual behaviour between
the immediate-treatment versus guideline-treated group. Forty-six per
cent of participants overall had had sex in the past month and 23%
had had casual sex. There was no significant difference in the proportion of
people reporting potentially risky sex: 10% of the early-treated
versus 12.8% of the guideline-treated, a non-significant difference
(p=0.17).

Whether
the sex had actually posed a risk depended, amongst other
things, on whether participants were virally suppressed. Whereas only 17.1% of those in the early-treated arm
had a viral load over 300
copies/ml, 89.5% of those in the guideline-treated arm did. Assuming that people with viral loads under 300 copies/ml are
uninfectious, the researchers calculated that only 2.4% of
early-treated participants, or only about 11 or 12 individuals, were
exposing their partners to potential HIV infection, compared with
11%, or over 100 individuals, in the guideline-treated arm.

This
implies a protective value of early antiretroviral treatment, in a trial that
was designed to measure risk behaviour rather than ART efficacy, of
about 90%.

Kenya/Uganda: obstacles in accessing ART

The
earlier people access ART, the more effect it has in preventing HIV.
But what are the barriers to early access? Data from a study of
pre-exposure prophylaxis (PrEP) provided interesting data on how soon
people actually start ART once they become eligible, and on the
reasons for delayed access.

Partners
PrEP randomised the HIV-negative partner in 4247
HIV-serodiscordant couples in Kenya and Uganda, where the
HIV-positive partner had a CD4 count above the WHO guidelines
threshold and was not on ART, either to receive PrEP or placebo. It
found PrEP to be 65% protective.

If
the HIV-positive partner's CD4 count fell below the guideline
threshold, they were immediately counselled to start ART and were
referred to a local HIV centre (the trial protocol did not allow for
the prescription of ART as treatment by the researchers themselves).
The data reported come from 2008 to 2011 and again, the treatment
threshold was raised in 2010 in line with the WHO guidelines
revision.

The
HIV-positive partner became treatment-eligible in 2178 of the couples
(51%) and was referred. Of these, 180 (8%) were lost to follow-up,
1998 attended for a follow-up visit at least once, and 1427 (71%) of
these started ART during the three-year trial. While there was delay
in accessing HIV – only 50% had started it within six months of
referral – most eventually started, with 90% of those who were
followed up for two years or more starting ART. As presenter Andrew
Mujugira showed, this access rate compared quite favourably
to the rates seen in a number of different cohort studies in the US.

However,
only 66% of those referred with a CD4 count below the AIDS-defining
limit of 200 cells/mm3, who were in danger of serious illness, began ART within six months of
referral, a proportion no higher than among those with CD4 counts between
200 and 350 cells/mm3.

Self-reported
barriers to accessing ART included protocols that mandated adherence
counselling before starting people on ART. One-third of HIV centres
expected participants to attend three adherence-counselling
appointments before starting ART: these might only be
monthly, so starting ART could be delayed by three months, and the
average delay between attending the first HIV centre appointment
and starting ART was 49 days in those receiving adherence counselling
versus 14 days in those not receiving it. There was no difference in
adherence or in the proportion achieving undetectable viral load
between those who received adherence counselling and those who did not.

Another
institutional barrier was that HIV centres insisted on re-doing the
participants' CD4 counts rather than accepting the referrers' result. As a result of this constraint 21% of referred participants were refused ART because their CD4
count at the HIV centre was actually somewhat above the ART
threshold. This may reflect short-term natural variations in CD4
count or different laboratory methods, but counts are unlikely to
start increasing over the long term in people not taking ART, so this is
likely to delay ART unnecessarily for those close to the treatment
threshold.

Botswana: attitudes towards taking ART

Partners
PrEP study participants were probably unusually well motivated to take ART
both as members of a jointly enrolled couple and because they already
had experience of their partner taking PrEP (or placebo). This may
not be the case in typical clinical settings. To explore some
attitudes towards taking ART in depth, a smaller study from Botswana
conducted semi-structured interviews and two focus groups with twelve
people with HIV (nine women and three men) from the same town,
Mochudi. All participants had CD4 counts over 350 cells/mm3
and viral loads over 50,000 copies/ml – so they were not yet
clinically eligible for ART but might be interested in its prevention
benefits.

The
interviews reinforced how important HIV stigma remains in Botswana,
despite or perhaps because of HIV's high prevalence. Participants
were well aware of the clinical benefits of ART but also cited being
no longer being visibly unwell as a good
reason to take ART. Conversely, some were worried about being
stigmatised because if people saw they were taking ART they would
know they had HIV.

Instances
of HIV stigma were commonly reported by the group: one women said
“There was one at our work, and it was known she had this disease.
Then I saw people scorned her... the others no longer used the
toilets that she used.”

Against
that, a number of participants had internalised the perception that,
these days, “it is a disease like anything else. It is the same as
being sick with diabetes.”

There
were concerns about side-effects, about the time and expense of going
to the HIV clinic and accessing ART, and again about disclosure and
stigma: people were worried that the HIV clinic was sited in the same
hospital that everyone went to. People also felt they were not
capable of the lifelong commitment to ART: one said “It is very
difficult, I don't know if I will get used to it or forget them”.

Another previously unexplored theme that arose in the discussions was a perceived link between ART
and drinking alcohol. The two were seen as incompatible, either for
reasons of interaction or because people were sure that drinking was
incompatible with adherence and would lead to treatment failure.
Taking ART was equated with sobriety, so people who drank were not
ready for it: “My partner takes [the pills] but he doesn't take
them well, because he is a drunkard”, one woman said. “He will be
out and the time will come for him to take them and he doesn't.”

Against
these barriers to ART, people cited experiences of friends recovering
from AIDS as the best facilitator for taking ART, and in particular
the fact that they can return to work: “You will see that a person
will not now be sick day after day, and they walk, they work, and
they were a patient who was just sleeping in blankets,” said a
61-year-old man.

The
prevention benefits of ART were also stressed and was also seen as
something that might help reduce stigma. “People should stop being
ashamed, they should stand on their feet and fight this disease so
that it finishes,” said one woman. “We should take these
[antivirals] so that the virus will reduce, and its spread.”

E-atlas

Uganda

E-atlas

ANRS (France REcherche Nord & Sud Sida-HIV et Hépatites)

Paris, France

Government agency; co-ordinates, evaluates and funds biological, vaccine, clinical, epidemiological and social research in France; organises and supports research programmes in developing countries in the HIV field; responsible for clinical and therapeutic research and public health relating to hepatitis C; publishes “ANRS Information” and “Sciences Sociales et SIDA”.

NAM’s IAS 2013 bulletins have been made possible thanks to support from Bristol-Myers Squibb. NAM's wider conference news reporting services have been supported by Boehringer Ingelheim and Janssen.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap

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checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member
of your healthcare team for advice tailored to your situation.